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Question 1
Incorrect
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A 75-year-old woman visits her general practitioner with a complaint of itchy white plaques on her vulva and inner thigh. She denies experiencing any vaginal discharge or bleeding. What is the probable diagnosis?
Your Answer: Lichen planus
Correct Answer: Lichen sclerosus
Explanation:Lichen sclerosus is a condition characterized by itchy white spots that are commonly observed on the vulva of older women. While candida can also cause itching and white patches, it would not result in lesions appearing on the inner thigh as well.
Understanding Lichen Sclerosus
Lichen sclerosus, previously known as lichen sclerosus et atrophicus, is an inflammatory condition that commonly affects the genitalia, particularly in elderly females. This condition leads to the atrophy of the epidermis, resulting in the formation of white plaques. The most prominent feature of lichen sclerosus is the presence of white patches that may scar. Patients may also experience itching and pain during intercourse or urination.
Diagnosis of lichen sclerosus is usually made based on clinical examination, but a biopsy may be performed if atypical features are present. Management of this condition involves the use of topical steroids and emollients. Patients with lichen sclerosus are at an increased risk of developing vulval cancer, and routine follow-up is necessary to monitor for any changes.
The Royal College of Obstetricians and Gynaecologists advise against performing a skin biopsy if a diagnosis can be made on clinical examination. However, a biopsy may be necessary if the patient fails to respond to treatment or if there is a suspicion of neoplastic change. The British Association of Dermatologists also recommends a biopsy if there are atypical features or diagnostic uncertainty. Patients under routine follow-up will need a biopsy if there is a suspicion of neoplastic change, if the disease fails to respond to treatment, if there is extragenital lichen sclerosus, or if second-line therapy is to be used.
Understanding lichen sclerosus is important for early diagnosis and management of this condition. Patients with this condition should seek medical attention if they experience any symptoms or changes in their condition.
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This question is part of the following fields:
- Dermatology
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Question 2
Incorrect
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A 43-year-old woman is diagnosed with premature ovarian failure and prescribed HRT for symptom relief and bone health. What other medical condition is she at a higher risk for?
Your Answer: Chronic Kidney disease
Correct Answer: Ischaemic heart disease
Explanation:Premature menopause is linked to higher mortality rates, including an increased risk of osteoporosis and cardiovascular disease, specifically ischaemic heart disease. Oestrogen is known to have protective effects on bone health and cardiovascular disease, making the increased risks associated with premature menopause particularly concerning. Hormone replacement therapy (HRT) is often recommended until the normal age of menopause, with a discussion of the risks and benefits of continuing HRT beyond that point. A 2015 NICE review found that the baseline risk of coronary heart disease and stroke for menopausal women varies based on individual cardiovascular risk factors. HRT with oestrogen alone is associated with no or reduced risk of coronary heart disease, while HRT with oestrogen and progestogen is linked to little or no increase in the risk of coronary heart disease. However, taking oral (but not transdermal) oestrogen is associated with a small increase in the risk of stroke.
Premature Ovarian Insufficiency: Causes and Management
Premature ovarian insufficiency is a condition where menopausal symptoms and elevated gonadotrophin levels occur before the age of 40. It affects approximately 1 in 100 women and can be caused by various factors such as idiopathic reasons, family history, bilateral oophorectomy, radiotherapy, chemotherapy, infection, autoimmune disorders, and resistant ovary syndrome. The symptoms of premature ovarian insufficiency are similar to those of normal menopause, including hot flushes, night sweats, infertility, secondary amenorrhoea, raised FSH and LH levels, and low oestradiol.
Management of premature ovarian insufficiency involves hormone replacement therapy (HRT) or a combined oral contraceptive pill until the age of the average menopause, which is 51 years. It is important to note that HRT does not provide contraception in case spontaneous ovarian activity resumes. Early diagnosis and management of premature ovarian insufficiency can help alleviate symptoms and improve quality of life for affected women.
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This question is part of the following fields:
- Cardiovascular
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Question 3
Incorrect
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A 32-year-old woman comes in for a check-up. She has been experiencing fatigue and has not had a regular period for the past 5 months. She previously had a consistent 28-day cycle. A pregnancy test is negative, her pelvic exam is normal, and routine blood work is ordered:
- Complete blood count: Normal
- Blood urea nitrogen and electrolytes: Normal
- Thyroid function test: Normal
- Follicle-stimulating hormone: 40 iu/l ( < 35 iu/l)
- Luteinizing hormone: 30 mIU/l (< 20 mIU/l)
- Oestradiol: 75 pmol/l ( > 100 pmol/l)
What is the most likely diagnosis?Your Answer: Aromatase enzyme deficiency
Correct Answer: Premature ovarian failure
Explanation:Premature Ovarian Insufficiency: Causes and Management
Premature ovarian insufficiency is a condition where menopausal symptoms and elevated gonadotrophin levels occur before the age of 40. It affects approximately 1 in 100 women and can be caused by various factors such as idiopathic reasons, family history, bilateral oophorectomy, radiotherapy, chemotherapy, infection, autoimmune disorders, and resistant ovary syndrome. The symptoms of premature ovarian insufficiency are similar to those of normal menopause, including hot flushes, night sweats, infertility, secondary amenorrhoea, raised FSH and LH levels, and low oestradiol.
Management of premature ovarian insufficiency involves hormone replacement therapy (HRT) or a combined oral contraceptive pill until the age of the average menopause, which is 51 years. It is important to note that HRT does not provide contraception in case spontaneous ovarian activity resumes. Early diagnosis and management of premature ovarian insufficiency can help alleviate symptoms and improve quality of life for affected women.
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This question is part of the following fields:
- Reproductive Medicine
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Question 4
Incorrect
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A typically healthy 68-year-old man visits the doctor's office complaining of feeling unwell. He mentions experiencing a sharp ache in his right groin. After three days, he develops a strip of painful, red blisters on the top of his right foot.
What is the most probable diagnosis?Your Answer: Herpes simplex
Correct Answer: Herpes zoster
Explanation:This individual is experiencing shingles, which is caused by the herpes zoster virus and is characterized by a unique distribution along a specific dermatome.
Shingles is a painful blistering rash caused by reactivation of the varicella-zoster virus. It is more common in older individuals and those with immunosuppressive conditions. The rash is well demarcated by the affected dermatome and may be accompanied by fever and lethargy. Treatment includes analgesia, antivirals, and potentially oral corticosteroids. Complications include post-herpetic neuralgia, ocular and ear complications. Antivirals should be used within 72 hours to reduce the risk of post-herpetic neuralgia.
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This question is part of the following fields:
- Dermatology
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Question 5
Incorrect
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A 49-year-old male presents to the neurology clinic with concerns about increasing numbness in his fingers and soles of his feet. He was diagnosed with epilepsy in his early twenties and has been managing his seizures effectively. Which medication is most likely responsible for his symptoms?
Your Answer: Levetiracetam
Correct Answer: Phenytoin
Explanation:Phenytoin is recognized to cause peripheral neuropathy as a side effect.
Phenytoin: Mechanism of Action and Adverse Effects
Phenytoin is a medication used to manage seizures. Its mechanism of action involves binding to sodium channels, which increases their refractory period. However, the drug is associated with a large number of adverse effects, which can be categorized as acute, chronic, idiosyncratic, and teratogenic. Acute effects include dizziness, diplopia, nystagmus, slurred speech, ataxia, confusion, and seizures. Chronic effects include gingival hyperplasia, hirsutism, coarsening of facial features, drowsiness, megaloblastic anemia, peripheral neuropathy, enhanced vitamin D metabolism causing osteomalacia, lymphadenopathy, and dyskinesia. Idiosyncratic effects include fever, rashes, hepatitis, Dupuytren’s contracture, aplastic anemia, and drug-induced lupus. Teratogenic effects are associated with cleft palate and congenital heart disease. Although routine monitoring of phenytoin levels is not necessary, trough levels should be checked before dosing in cases of dose adjustment, suspected toxicity, or non-adherence to the prescribed medication.
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This question is part of the following fields:
- Neurology
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Question 6
Correct
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A 32-year-old female patient presents to her GP with worries regarding her medication. She was diagnosed with systemic lupus erythematosus 2 years ago and is currently on azathioprine 120mg/day, divided into doses. She recently took a home pregnancy test which came back positive. What is the most appropriate approach to managing her medication?
Your Answer: Continue azathioprine
Explanation:It is safe to continue using azathioprine during pregnancy, even if on an established dose. Discontinuing or reducing the medication could lead to disease progression and serious health risks for the patient. Therefore, the dose of azathioprine should not be lowered. Switching to corticosteroids would not be appropriate as the patient is already on a safe medication. Infliximab should only be used if necessary during pregnancy, so continuing with azathioprine is a better option. Methotrexate should never be used during pregnancy as it is known to be teratogenic.
Azathioprine is a medication that is broken down into mercaptopurine, which is an active compound that inhibits the production of purine. To determine if someone is at risk for azathioprine toxicity, a test for thiopurine methyltransferase (TPMT) may be necessary. Adverse effects of this medication include bone marrow depression, which can be detected through a full blood count if there are signs of infection or bleeding, as well as nausea, vomiting, pancreatitis, and an increased risk of non-melanoma skin cancer. It is important to note that there is a significant interaction between azathioprine and allopurinol, so lower doses of azathioprine should be used in conjunction with allopurinol. Despite these potential side effects, azathioprine is generally considered safe to use during pregnancy.
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This question is part of the following fields:
- Musculoskeletal
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Question 7
Incorrect
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A 68-year-old woman presents with a 2-week history of fatigue, pain and stiffness in her hips and shoulders, low mood, and loss of appetite. The pain and stiffness is worst first thing in the morning. Blood tests are shown below:
Hb 126 g/L
Male: (135-180)
Female: (115 - 160)
Platelets 288 * 109/L
(150 - 400)
WBC 9.8 * 109/L
(4.0 - 11.0)
ESR 78 mm/hr
Men: < (age / 2)
Women: < ((age + 10) / 2)
CRP 56 mg/L
(< 5)
The patient is suspected to have polymyalgia rheumatica and is started on prednisolone. However, after 3 weeks, her symptoms have not improved. What is the most appropriate next step?Your Answer:
Correct Answer: Consider an alternative diagnosis
Explanation:If a patient with polymyalgia rheumatica does not respond well to steroids, it is important to consider other possible diagnoses. Typically, patients with this condition experience a dramatic improvement in symptoms within two weeks of starting steroid treatment. Therefore, if there is no response, it is unlikely that polymyalgia rheumatica is the correct diagnosis. Other conditions that may be considered include rheumatoid arthritis, hypothyroidism, fibromyalgia, and polymyositis. Continuing with the same dose of prednisolone or increasing the dose is not recommended, as there should have been some response to the initial dose if polymyalgia rheumatica was present. Similarly, replacing oral prednisolone with IV methylprednisolone is not appropriate if there has been no response to the oral medication. Methotrexate is a second-line treatment option for polymyalgia rheumatica, but it is not the most appropriate next step if the diagnosis is uncertain.
Polymyalgia Rheumatica: A Condition of Muscle Stiffness in Older People
Polymyalgia rheumatica (PMR) is a common condition that affects older people. It is characterized by muscle stiffness and elevated inflammatory markers. Although it is closely related to temporal arteritis, the underlying cause is not fully understood, and it does not appear to be a vasculitic process. PMR typically affects patients over the age of 60 and has a rapid onset, usually within a month. Patients experience aching and morning stiffness in proximal limb muscles, along with mild polyarthralgia, lethargy, depression, low-grade fever, anorexia, and night sweats.
To diagnose PMR, doctors look for raised inflammatory markers, such as an ESR of over 40 mm/hr. Creatine kinase and EMG are normal. Treatment for PMR involves prednisolone, usually at a dose of 15mg/od. Patients typically respond dramatically to steroids, and failure to do so should prompt consideration of an alternative diagnosis.
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This question is part of the following fields:
- Musculoskeletal
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Question 8
Incorrect
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A 62-year-old man is admitted to the Acute Medical Ward with lower back pain. He has a past medical history of prostate cancer and hypertension. His pain radiates down the left leg and he has reduced power in that leg. He also has a reduced anal tone. The lumbar spine X-ray shows no obvious fracture and there is no history of trauma.
Given the likely diagnosis of metastatic spinal cord compression (MSCC), he was referred urgently for oncological and neurosurgical assessment.
Which medication is the patient most likely to be started on?Your Answer:
Correct Answer: High-dose dexamethasone
Explanation:Treatment Options for Metastatic Spinal Cord Compression
Metastatic spinal cord compression (MSCC) is a serious condition that requires urgent medical attention. Red flags for lower back pain include associated lower limb pain, limb weakness, paraesthesia/numbness, and reduced perianal tone. If these features are present, especially in a patient with an oncological past medical history, urgent magnetic resonance imaging (MRI) should be performed to rule out spinal cord compression.
Patients with MSCC should be referred urgently to the oncology and neurosurgical teams for immediate treatment and consideration of surgical intervention to relieve the compression. Management should include high-dose oral dexamethasone and urgent oncological assessment for consideration of radiotherapy or surgery. Diclofenac is not indicated in MSCC treatment, and high-dose prednisolone is not the corticosteroid of choice.
Intravenous ceftriaxone is not effective in treating MSCC, as it is used to treat meningitis. Intravenous immunoglobulin therapy is also not indicated in MSCC treatment, as it is used to treat conditions such as immune thrombocytopenia, Kawasaki disease, and Guillain–Barré syndrome.
In conclusion, early recognition and prompt treatment of MSCC are crucial to prevent permanent neurological damage. High-dose dexamethasone and urgent oncological assessment for consideration of radiotherapy or surgery are the recommended treatment options for MSCC.
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This question is part of the following fields:
- Neurology
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Question 9
Incorrect
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An anxious, 30-year-old saleswoman presents with mild shortness of breath on exertion, which had come on gradually over several months. The symptom was intermittent and seemed to get worse in the evening. She has also been on treatment for depression over the last two months. On examination, she has minimal weakness of shoulder abductors and slight weakness of eye closure bilaterally. Deep tendon reflexes are present and symmetrical throughout and plantar responses are flexor. You now have the results of the investigations: FBC, U&E, LFT, TFT - normal; chest radiograph and lung function tests - normal; ECG - normal.
Which of the following is the most likely diagnosis?
Select the SINGLE most likely diagnosis.Your Answer:
Correct Answer: Myasthenia gravis
Explanation:Understanding Myasthenia Gravis: Symptoms, Diagnosis, and Treatment
Myasthenia gravis (MG) is a neuromuscular disorder that occurs when the body produces autoantibodies against the nicotinic acetylcholine receptor at the neuromuscular junction. This results in muscular weakness that is characterized by fatigability, meaning that the muscles become increasingly weaker during their use. MG primarily affects the muscles of the face, the extrinsic ocular muscles (causing diplopia), and the muscles involved in deglutition. Respiratory and proximal lower limb muscles may also be involved early in the disease, which can cause breathlessness and even sudden death.
Diagnosing MG can be challenging, as weakness may not be apparent on a single examination. However, electrodiagnostic tests and detecting the autoantibodies can confirm the diagnosis. The Tensilon test, which involves injecting edrophonium chloride to reverse the symptoms of MG, is now used only when other tests are negative and clinical suspicion of MG is still high.
Treatment of MG involves anticholinesterase medications, but many patients also benefit from thymectomy. It is important to note that a thymoma may be present in up to 15% of patients with MG.
Other conditions, such as transient ischaemic attacks, angina, multiple sclerosis, and somatisation disorder, may cause weakness, but they do not typically present with the same symptoms as MG. Therefore, it is crucial to consider MG as a potential diagnosis when a patient presents with fatigable muscular weakness.
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This question is part of the following fields:
- Respiratory Medicine
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Question 10
Incorrect
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A 35-year-old man presents to his General Practitioner with difficulty breathing during physical activity and feeling excessively tired. Upon further inquiry, he reports experiencing frequent respiratory infections. The doctor suspects a diagnosis of alpha-1-antitrypsin deficiency (AATD).
What test should be arranged to confirm this diagnosis?Your Answer:
Correct Answer: Blood test for alpha-1-antitrypsin levels
Explanation:Diagnostic Tests for Alpha-1-Antitrypsin Deficiency
Alpha-1-antitrypsin deficiency (AATD) is a genetic disorder that can lead to chronic obstructive pulmonary disease (COPD) at a young age, especially in non-smokers with a family history of the condition. Here are some diagnostic tests that can help identify AATD:
Blood Test: A simple blood test can measure the levels of alpha-1-antitrypsin in the blood. Low levels of this protein can indicate AATD, especially in patients with symptoms of COPD or a family history of the condition.
CT Chest: A computed tomography (CT) scan of the chest can reveal the extent and pattern of emphysema in the lungs, which is a common complication of AATD. However, a CT scan alone cannot diagnose AATD.
Chest X-Ray: A chest X-ray (CXR) can also show signs of emphysema or bronchiectasis in patients with AATD, but it is not a definitive test for the condition.
Genetic Testing: Once AATD has been diagnosed, genetic testing can identify the specific variant of the condition that a patient has. However, genetic testing is not useful as an initial diagnostic test without first confirming low levels of alpha-1-antitrypsin in the blood.
Pulmonary Function Testing: This test measures lung function and can help assess the severity of lung disease in patients with AATD. However, it is not a diagnostic test for the condition.
In conclusion, a combination of these diagnostic tests can help identify AATD in patients with symptoms of COPD, a family history of the condition, or low levels of alpha-1-antitrypsin in the blood.
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This question is part of the following fields:
- Respiratory Medicine
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Question 11
Incorrect
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A 72-year-old man has recently been diagnosed with heart failure. He is currently taking ramipril for his high blood pressure. What is the most appropriate medication to help manage his heart failure?
Your Answer:
Correct Answer: Bisoprolol
Explanation:Comparing Beta Blockers for Heart Failure: Efficacy and Evidence
Beta blockers are a class of medications commonly used in the treatment of heart failure. Among them, bisoprolol and carvedilol have the strongest evidence of efficacy in reducing mortality rates in heart failure patients, according to data from the CIBIS and CASA-2 trials. Atenolol, although cardioselective, has less evidence to support its use in heart failure. Labetalol is primarily used for hypertension in pregnancy, while propranolol has the most evidence of benefit after a myocardial infarction but is not always preferred due to its twice-daily dosing. Sotalol, a first-generation beta blocker, is not cardioselective and is not recommended for heart failure. Overall, the choice of beta blocker for heart failure should be based on the available evidence and individual patient factors.
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This question is part of the following fields:
- Cardiovascular
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Question 12
Incorrect
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A 50-year-old man is brought to the Emergency Department by his wife after developing a severe cutaneous hypersensitivity reaction. He has a history of rheumatoid arthritis for which he was taking non-steroidal anti-inflammatory drugs (NSAIDs). Still, his symptoms did not improve, and his rheumatologist prescribed him methotrexate a few days ago.
On examination, Nikolsky’s sign is present and affects 45% of his body’s surface area.
What is the underlying condition?Your Answer:
Correct Answer: Toxic epidermal necrolysis
Explanation:Common Skin Hypersensitivity Reactions and their Causes
Skin hypersensitivity reactions can range from mild to life-threatening. Here are some common types and their causes:
Toxic Epidermal Necrolysis: This is the most serious skin hypersensitivity reaction, with a high mortality rate. It is usually caused by drugs such as NSAIDs, steroids, methotrexate, allopurinol and penicillins.
Erythema Multiforme: This is a target-like lesion that commonly occurs on the palms and soles. It is usually caused by drugs such as penicillins, phenytoin, NSAIDs and sulfa drugs. Mycoplasma and herpes simplex infections can also cause erythema multiforme.
Erythema Nodosum: This is an inflammatory condition of subcutaneous tissue. The most common causes are recent streptococcal infection, sarcoidosis, tuberculosis and inflammatory bowel disease.
Fixed Drug Reaction: This is a localised allergic drug reaction that recurs at the same anatomic site of the skin with repeated drug exposure. It is most commonly caused by aspirin, NSAIDs, tetracycline and barbiturate.
Morbilliform Rash: This is a mild hypersensitivity skin reaction that manifests as a generalised maculopapular eruption that blanches with pressure. The rash can be caused by penicillin, sulfa drugs, allopurinol and phenytoin.
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This question is part of the following fields:
- Dermatology
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Question 13
Incorrect
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You are contemplating prescribing mefloquine as a prophylaxis for malaria for a 26-year-old female. What is the most crucial contraindication to keep in mind?
Your Answer:
Correct Answer: A history of anxiety or depression
Explanation:Strengthened Warnings on the Neuropsychiatric Side-Effects of Mefloquine
Mefloquine, also known as Lariam, is a medication used for the prevention and treatment of certain types of malaria. However, there has been a long-standing concern about its potential neuropsychiatric side-effects. A recent review has led to strengthened warnings about the risks associated with mefloquine.
Patients taking mefloquine may experience side-effects such as nightmares or anxiety, which could be a warning sign of a more serious neuropsychiatric event. There have been reports of suicide and deliberate self-harm in patients taking mefloquine. Adverse reactions may also continue for several months due to the long half-life of the medication.
It is important to note that mefloquine should not be used in patients with a history of anxiety, depression, schizophrenia, or other psychiatric disorders. If patients experience any neuropsychiatric side-effects while taking mefloquine, they should stop taking the medication and seek medical advice. These strengthened warnings aim to ensure that patients are fully informed about the potential risks associated with mefloquine.
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This question is part of the following fields:
- Pharmacology/Therapeutics
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Question 14
Incorrect
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A 65-year-old man is admitted to the hospital with severe abdominal pain that is typically worst shortly after eating a meal. He admits to regularly drinking at least 30 units of alcohol per week for the last 35 years and has recently been diagnosed with type 2 diabetes mellitus by his GP. An abdominal CT scan shows calcification of his pancreas.
What tests can be used to assess the exocrine function of the pancreas, given the likely diagnosis?Your Answer:
Correct Answer: Faecal elastase
Explanation:The most appropriate test to assess exocrine function in chronic pancreatitis is faecal elastase. This is particularly relevant for a patient who has a history of long-term alcohol consumption and has recently been diagnosed with diabetes, which are both common complications of chronic pancreatitis. Faecal calprotectin is not relevant in this context as it is used to diagnose inflammatory bowel diseases. Serum amylase may not be useful in chronic pancreatitis as patients may have normal levels despite loss of pancreatic function. Serum calcium is not used to assess pancreatic function in chronic pancreatitis, but is part of the Glasgow score for acute pancreatitis. Lipase is not typically used to assess exocrine function, but deficiency in this enzyme can lead to steatorrhoea in patients with chronic pancreatitis.
Understanding Chronic Pancreatitis
Chronic pancreatitis is a condition characterized by inflammation that can affect both the exocrine and endocrine functions of the pancreas. While alcohol excess is the leading cause of this condition, up to 20% of cases are unexplained. Other causes include genetic factors such as cystic fibrosis and haemochromatosis, as well as ductal obstruction due to tumors, stones, and structural abnormalities like pancreas divisum and annular pancreas.
Symptoms of chronic pancreatitis include pain that worsens 15 to 30 minutes after a meal, steatorrhoea, and diabetes mellitus. Abdominal x-rays can show pancreatic calcification in 30% of cases, while CT scans are more sensitive at detecting calcification with a sensitivity of 80% and specificity of 85%. Functional tests like faecal elastase may be used to assess exocrine function if imaging is inconclusive.
Management of chronic pancreatitis involves pancreatic enzyme supplements, analgesia, and antioxidants, although the evidence base for the latter is limited. It is important to understand the causes, symptoms, and management of chronic pancreatitis to effectively manage this condition.
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This question is part of the following fields:
- Gastroenterology/Nutrition
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Question 15
Incorrect
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What is the primary mode of action of Cerazette (desogestrel)?
Your Answer:
Correct Answer: Inhibits ovulation
Explanation:Types of Progestogen Only Pills
Progestogen only pills (POPs) are a type of birth control pill that contain only progestogen hormone. There are two generations of POPs, with the second generation including norethisterone, levonorgestrel, and ethynodiol diacetate. The third generation of POPs includes desogestrel, which is also known as Cerazette. This new type of POP is highly effective in inhibiting ovulation in most women. One of the advantages of Cerazette is that users can take the pill up to 12 hours late, which is longer than the 3-hour window for other POPs. Overall, there are different types of POPs available, and women can choose the one that best suits their needs and preferences.
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This question is part of the following fields:
- Reproductive Medicine
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Question 16
Incorrect
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A 6-day-old boy is brought to his General Practitioner by his mother, who has noticed a yellow tinge to his sclera and skin. He is being breastfed. He is otherwise well and had a normal newborn blood-spot test.
What is the most likely diagnosis?
Your Answer:
Correct Answer: Breastmilk jaundice
Explanation:Possible Causes of Jaundice in a Breastfed Baby: Excluding Cystic Fibrosis, Galactosaemia, ABO Incompatibility, and Hypothyroidism
Breastmilk jaundice is a common cause of jaundice in healthy, breastfed babies beyond two weeks of age. However, other potential causes should still be screened for. The exact mechanism of breastmilk jaundice is unknown, but breastfeeding should continue and bilirubin levels should be monitored. If levels are above the treatment line, phototherapy may be necessary. Jaundice can persist for up to 12 weeks in some cases. Cystic fibrosis is excluded as a diagnosis if the newborn blood-spot test is normal. Galactosaemia is unlikely if the baby has not shown symptoms such as difficulty feeding, vomiting, and faltering growth. ABO incompatibility typically presents within the first 24 hours of life, so it is unlikely if symptoms appear eight days after birth. Hypothyroidism is screened for in the newborn blood-spot test, and normal results exclude it as a diagnosis.
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This question is part of the following fields:
- Paediatrics
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Question 17
Incorrect
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A 68-year-old male is prescribed colchicine to alleviate his gout symptoms that are not responding to diclofenac. What is the most crucial side effect to caution him about?
Your Answer:
Correct Answer: Diarrhoea
Explanation:Gout is caused by chronic hyperuricaemia and is managed acutely with NSAIDs or colchicine. Urate-lowering therapy (ULT) is recommended for patients with >= 2 attacks in 12 months, tophi, renal disease, uric acid renal stones, or prophylaxis if on cytotoxics or diuretics. Allopurinol is first-line ULT, with an initial dose of 100 mg od and titrated to aim for a serum uric acid of < 300 µmol/l. Lifestyle modifications include reducing alcohol intake, losing weight if obese, and avoiding high-purine foods. Consideration should be given to stopping precipitating drugs and losartan may be suitable for patients with coexistent hypertension.
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This question is part of the following fields:
- Musculoskeletal
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Question 18
Incorrect
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A 28-year-old woman is being seen in the asthma clinic. She is currently on salbutamol inhaler 100mcg prn and beclometasone dipropionate inhaler 400 mcg bd, but is experiencing frequent asthma exacerbations and has recently undergone a course of prednisolone. In accordance with NICE guidelines, what would be the most suitable course of action for her management?
Your Answer:
Correct Answer: Add a leukotriene receptor antagonist
Explanation:According to NICE 2017 guidelines, if a patient with asthma is not effectively managed with a SABA + ICS, the first step should be to add a LTRA rather than a LABA.
The management of asthma in adults has been updated by NICE in 2017, following the 2016 BTS guidelines. One of the significant changes is in ‘step 3’, where patients on a SABA + ICS whose asthma is not well controlled should be offered a leukotriene receptor antagonist instead of a LABA. NICE does not follow the stepwise approach of the previous BTS guidelines, but to make the guidelines easier to follow, we have added our own steps. The steps range from newly-diagnosed asthma to SABA +/- LTRA + one of the following options, including increasing ICS to high-dose, a trial of an additional drug, or seeking advice from a healthcare professional with expertise in asthma. Maintenance and reliever therapy (MART) is a form of combined ICS and LABA treatment that is only available for ICS and LABA combinations in which the LABA has a fast-acting component. It should be noted that NICE does not recommend changing treatment in patients who have well-controlled asthma simply to adhere to the latest guidance. The definitions of what constitutes a low, moderate, or high-dose ICS have also changed, with <= 400 micrograms budesonide or equivalent being a low dose, 400 micrograms - 800 micrograms budesonide or equivalent being a moderate dose, and > 800 micrograms budesonide or equivalent being a high dose for adults.
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This question is part of the following fields:
- Respiratory Medicine
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Question 19
Incorrect
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A 52-year-old woman presents to an eye screening appointment, having been referred by her General Practitioner. She has a family history of type II diabetes mellitus. At the appointment, there are no signs of diabetic retinopathy.
What is the most appropriate ongoing eye screening for this patient?Your Answer:
Correct Answer: Annual visual acuity testing and retinal photography
Explanation:The Importance of Annual Eye Screening for Diabetic Patients
The National Health Service diabetic eye screening programme recommends that patients over the age of 12 with diabetes attend annual eye screening appointments. These appointments include visual acuity testing and retinal photography, which can detect changes consistent with background retinopathy or more severe forms of diabetic retinopathy. Patients with moderate, severe, or proliferative retinopathy will be referred for further assessment and may require more frequent screening following treatment.
Tonometry, which measures intraocular pressure, is also important in the diagnosis of glaucoma. However, the gold-standard test for diagnosing diabetic retinopathy is dilated retinal photography with or without fundoscopy. Retinal photographs are preferable to fundoscopy because they provide a clear view of the entire retina and can be compared with previous images to monitor disease progression.
It is important for diabetic patients to attend annual eye screening appointments, even if they have no changes in vision. Vision may be preserved until relatively advanced stages of the disease, and early detection of diabetic retinopathy can prevent irreversible loss of vision. Therefore, patients should not wait for changes in vision to occur before attending screening appointments.
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This question is part of the following fields:
- Ophthalmology
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Question 20
Incorrect
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A 50-year-old man with a persistent chest infection visits the clinic for evaluation. Despite two rounds of antibiotics, there has been no significant improvement. The medical team decides to conduct a chest x-ray and screening blood tests. When analyzing the blood tests, which of the following markers is typically not elevated in response to an acute infection?
Your Answer:
Correct Answer: Albumin
Explanation:A decrease in albumin levels is frequently observed after an acute phase response.
Acute phase proteins are a group of proteins that are produced by the liver in response to inflammation or infection. These proteins are involved in various physiological processes such as immune response, blood clotting, and iron metabolism. Examples of acute phase proteins include CRP, procalcitonin, ferritin, fibrinogen, alpha-1 antitrypsin, caeruloplasmin, serum amyloid A, serum amyloid P component, haptoglobin, and complement.
During the acute phase response, the liver decreases the production of other proteins known as negative acute phase proteins. These proteins include albumin, transthyretin, transferrin, retinol binding protein, and cortisol binding protein. The levels of acute phase proteins, particularly CRP, are commonly measured in acutely unwell patients. Elevated levels of CRP are indicative of inflammation or infection, and levels greater than 150 at 48 hours post-surgery suggest the development of complications.
It is important to note that while acute phase proteins play a significant role in humans, some of these proteins, such as serum amyloid P component, have a more significant role in other mammals like mice. Overall, the production of acute phase proteins is a crucial part of the body’s response to inflammation or infection, and monitoring their levels can aid in the diagnosis and management of various medical conditions.
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This question is part of the following fields:
- Infectious Diseases
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Question 21
Incorrect
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A 45-year-old patient was referred with a 2-year history of persistent cough productive of yellowish sputum throughout the year. He has been treated by his GP for frequent chest infections.
Which of the following is the most likely diagnosis?
Your Answer:
Correct Answer: Bronchiectasis
Explanation:Bronchiectasis: Causes, Symptoms, and Treatment
Bronchiectasis is a condition characterized by permanent and irreversible dilatations of the bronchial walls. It can be caused by various factors, including cystic fibrosis, immune system deficiencies, lung infections, foreign body aspiration, and smoking. Common symptoms of bronchiectasis include high sputum production, recurrent chest infections, and frequent but usually not severe haemoptysis. Patients may also experience postnasal drip, chronic sinusitis, and undue tiredness. A high-resolution computed tomography (HR-CT) scan is usually used to diagnose bronchiectasis. Treatment involves a multidisciplinary approach, including chest physiotherapy, patient education on airway-clearing techniques, antibiotic treatment during infective exacerbations, and bronchodilators in case of airflow obstruction. While treatment of the underlying cause may be necessary, it does not provide reversal of the existing bronchiectasis. Other conditions, such as sarcoidosis, fibrosing alveolitis, lung cancer, and asthma, are unlikely to produce the same clinical picture as bronchiectasis.
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This question is part of the following fields:
- Respiratory Medicine
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Question 22
Incorrect
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A 62-year-old woman presents to her General Practitioner complaining of a 3-day history of acute left-sided abdominal pain, diarrhoea and fever. She has a history of chronic constipation. On examination she is tachycardic and there is localised peritonism in the left iliac fossa.
What would be the next most appropriate step in this patient’s management?
Your Answer:
Correct Answer: Admit to hospital under the surgical team for investigation and management
Explanation:Differentiating Appropriate Management Strategies for Diverticulitis: A Guide for Healthcare Professionals
Diverticulitis is a common condition that can lead to serious complications if not managed appropriately. As a healthcare professional, it is important to understand the different management strategies available and when they are appropriate. Here are some scenarios and the recommended management strategies:
1. Admit to hospital under the surgical team for investigation and management: This is the recommended management strategy for a patient with peritonitis secondary to diverticulitis. The surgical team may choose to use imaging investigations first or proceed straight to surgery for operative management.
2. Admit to hospital for urgent magnetic resonance imaging (MRI) enterography: MRI enterography is not usually used in diverticular disease. A CT scan would be quicker and would provide the required information needed to evaluate whether or not the patient needs emergency surgery.
3. Analgesia and fluids and review in 24 hours: This management strategy is not appropriate for a patient with severe diverticulitis and peritonism. Urgent intravenous antibiotics and fluid management in the hospital are needed.
4. Arrange a stool sample and commence antibiotics in the community: A stool sample is unlikely to provide any additional information in this scenario. Urgent admission to the hospital for further management is needed.
5. Admit to hospital for urgent colonoscopy: Performing a colonoscopy on an inflamed bowel would be inappropriate since the risk of perforation would be high. A colonoscopy is sometimes used to evaluate the patient after the diverticulitis is present, to exclude other intramural pathology.
In conclusion, appropriate management strategies for diverticulitis depend on the severity of the condition and the presence of complications. Healthcare professionals should be aware of the different options available and choose the most appropriate one for each patient.
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This question is part of the following fields:
- Gastroenterology/Nutrition
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Question 23
Incorrect
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A 25-year-old man is brought into the emergency department resus, after being involved in a road traffic collision, where he, a motorbike rider, collided with a car. As one of the doctors receiving the patient into resus, you are tasked with calculating the current Glasgow coma score (GCS) of the patient. The patient's eyes are open, but he seems disoriented and asks you if he's on a spaceship.
Your Answer:
Correct Answer: 13
Explanation:The patient’s GCS score is 13, with a breakdown of 4 out of 4 for eye opening, 4 out of 5 for verbal response (due to confusion), and 5 out of 6 for motor response (exhibiting localisation to pain). A helpful mnemonic to remember this breakdown is 654…MoVE.
Understanding the Glasgow Coma Scale for Adults
The Glasgow Coma Scale (GCS) is a tool used to assess the level of consciousness in adults who have suffered a brain injury or other neurological condition. It is based on three components: motor response, verbal response, and eye opening. Each component is scored on a scale from 1 to 6, with a higher score indicating a better level of consciousness.
The motor response component assesses the patient’s ability to move in response to stimuli. A score of 6 indicates that the patient is able to obey commands, while a score of 1 indicates no movement at all.
The verbal response component assesses the patient’s ability to communicate. A score of 5 indicates that the patient is fully oriented, while a score of 1 indicates no verbal response at all.
The eye opening component assesses the patient’s ability to open their eyes. A score of 4 indicates that the patient is able to open their eyes spontaneously, while a score of 1 indicates no eye opening at all.
The GCS score is expressed as a combination of the scores from each component, with the motor response score listed first, followed by the verbal response score, and then the eye opening score. For example, a GCS score of 13, M5 V4 E4 at 21:30 would indicate that the patient had a motor response score of 5, a verbal response score of 4, and an eye opening score of 4 at 9:30 PM.
Overall, the Glasgow Coma Scale is a useful tool for healthcare professionals to assess the level of consciousness in adults with neurological conditions.
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This question is part of the following fields:
- Neurology
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Question 24
Incorrect
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A 48-year-old woman comes to the clinic for advice on contraception. She has started a new relationship but is uncertain if she needs contraception as she suspects she may be going through menopause. She reports experiencing hot flashes and her last period was 9 months ago. What is the best course of action to recommend?
Your Answer:
Correct Answer: Contraception is needed until 12 months after her last period
Explanation:Contraception is still necessary after menopause. Women who are over 50 years old should use contraception for at least 12 months after their last period, while those under 50 years old should use it for at least 24 months after their last period.
Understanding Menopause and Contraception
Menopause is a natural biological process that marks the end of a woman’s reproductive years. On average, women in the UK experience menopause at the age of 51. However, prior to menopause, women may experience a period known as the climacteric. During this time, ovarian function starts to decline, and women may experience symptoms such as hot flashes, mood swings, and vaginal dryness.
It is important for women to understand that they can still become pregnant during the climacteric period. Therefore, it is recommended to use effective contraception until a certain period of time has passed. Women over the age of 50 should use contraception for 12 months after their last period, while women under the age of 50 should use contraception for 24 months after their last period. By understanding menopause and the importance of contraception during the climacteric period, women can make informed decisions about their reproductive health.
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This question is part of the following fields:
- Reproductive Medicine
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Question 25
Incorrect
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A 67-year-old man attending the respiratory clinic receives a suspected diagnosis of chronic obstructive pulmonary disease.
Which of the following is the most appropriate investigation to confirm diagnosis?Your Answer:
Correct Answer: Spirometry
Explanation:Investigations for COPD: Spirometry is Key
COPD is a chronic obstructive airway disease that is diagnosed through a combination of clinical history, signs, and investigations. While several investigations may be used to support a diagnosis of COPD, spirometry is the most useful and important tool. A spirometer is used to measure functional lung volumes, including forced expiratory volume in 1 s (FEV1) and forced vital capacity (FVC). The FEV1:FVC ratio provides an estimate of the severity of airflow obstruction, with a normal ratio being 75-80%. In patients with COPD, the ratio is typically <0.7 and FEV1 <80% predicted. Spirometry is essential for establishing a baseline for disease severity, monitoring disease progression, and assessing the effects of treatment. Other investigations, such as echocardiography, chest radiography, ECG, and peak flow, may be used to exclude other pathologies or assess comorbidities, but spirometry remains the key investigation for diagnosing and managing COPD.
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This question is part of the following fields:
- Respiratory Medicine
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Question 26
Incorrect
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A 32-year-old female presents with a purpuric rash on the back of her legs, frequent nose bleeds, and menorrhagia. She is currently taking Microgynon 30. A full blood count reveals Hb of 11.7 g/dl, platelets of 62 * 109/l, and WCC of 5.3 * 109/l. What is the probable diagnosis?
Your Answer:
Correct Answer: Idiopathic thrombocytopenic purpura
Explanation:A diagnosis of ITP is suggested by the presence of isolated thrombocytopenia in a healthy patient. Blood dyscrasias are not typically caused by the use of combined oral contraceptive pills.
Understanding Immune Thrombocytopenia (ITP) in Adults
Immune thrombocytopenia (ITP) is a condition where the immune system attacks and reduces the number of platelets in the blood. This is caused by antibodies targeting the glycoprotein IIb/IIIa or Ib-V-IX complex. While children with ITP usually experience acute thrombocytopenia after an infection or vaccination, adults tend to have a more chronic form of the condition. ITP is more common in older females and may be detected incidentally during routine blood tests. Symptoms may include petechiae, purpura, and bleeding, but catastrophic bleeding is not a common presentation.
To diagnose ITP, a full blood count and blood film are typically performed. While a bone marrow examination is no longer routinely used, antiplatelet antibody testing may be done, although it has poor sensitivity and does not affect clinical management. The first-line treatment for ITP is oral prednisolone, but pooled normal human immunoglobulin (IVIG) may also be used if active bleeding or an urgent invasive procedure is required. Splenectomy is now less commonly used as a treatment option.
In some cases, ITP may be associated with autoimmune haemolytic anaemia (AIHA), which is known as Evan’s syndrome. It is important for individuals with ITP to work closely with their healthcare provider to manage their condition and prevent complications.
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This question is part of the following fields:
- Haematology/Oncology
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Question 27
Incorrect
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You are assessing a 55-year-old man who has been admitted with pneumonia. His medical history indicates that he consumes approximately 70-80 units of alcohol per week. Which medication would be the most suitable to administer to prevent the onset of alcohol withdrawal symptoms?
Your Answer:
Correct Answer: Chlordiazepoxide
Explanation:Alcohol withdrawal occurs when an individual who has been consuming alcohol chronically suddenly stops or reduces their intake. Chronic alcohol consumption enhances the inhibitory effects of GABA in the central nervous system, similar to benzodiazepines, and inhibits NMDA-type glutamate receptors. However, alcohol withdrawal leads to the opposite effect, resulting in decreased inhibitory GABA and increased NMDA glutamate transmission. Symptoms of alcohol withdrawal typically start at 6-12 hours and include tremors, sweating, tachycardia, and anxiety. Seizures are most likely to occur at 36 hours, while delirium tremens, which includes coarse tremors, confusion, delusions, auditory and visual hallucinations, fever, and tachycardia, peak at 48-72 hours.
Patients with a history of complex withdrawals from alcohol, such as delirium tremens, seizures, or blackouts, should be admitted to the hospital for monitoring until their withdrawals stabilize. The first-line treatment for alcohol withdrawal is long-acting benzodiazepines, such as chlordiazepoxide or diazepam, which are typically given as part of a reducing dose protocol. Lorazepam may be preferable in patients with hepatic failure. Carbamazepine is also effective in treating alcohol withdrawal, while phenytoin is said to be less effective in treating alcohol withdrawal seizures.
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This question is part of the following fields:
- Psychiatry
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Question 28
Incorrect
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A 32-year-old man has had severe left-sided facial pain with purulent nasal discharge for ten days. He describes how he initially felt 'okay' with milder symptoms, but noticed a sudden deterioration in his symptoms a few days ago.
Which of the following treatments would be the treatment of choice?Your Answer:
Correct Answer: Phenoxymethylpenicillin
Explanation:Treatment Options for Acute Sinusitis: Antibiotics, Decongestants, and Antihistamines
Acute bacterial sinusitis is a common condition that can cause severe symptoms such as discolored or purulent discharge, severe localized pain, and fever. Antibiotics are prescribed only if the patient has a co-morbidity or if acute bacterial sinusitis is clinically suspected. The antibiotics of choice include amoxicillin, phenoxymethylpenicillin, doxycycline, or erythromycin. Second-line treatments include co-amoxiclav and azithromycin.
Decongestants such as ephedrine can be used to relieve nasal congestion, but they should not be used for more than seven days to avoid rebound congestion. Antihistamines such as chlorpheniramine are not recommended unless there is a coexisting allergic rhinitis.
It is important to note that flucloxacillin and metronidazole are not the antibiotics of choice for acute sinusitis. Doxycycline or erythromycin are acceptable alternatives. Treatment should be used only for persistent symptoms or purulent nasal discharge lasting at least 7 days, or if the symptoms are severe.
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This question is part of the following fields:
- ENT
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Question 29
Incorrect
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A 38-year-old man presents with pruritic, violaceous papules in a polygonal pattern on the flexor surface of his forearms. Several of these papules have merged to form plaques. What is the probable diagnosis?
Your Answer:
Correct Answer: Lichen planus
Explanation:Lichen planus is a rash that appears as purple, itchy, polygonal papules on the flexor surfaces of the body. It is often accompanied by Wickham’s striae on the surface and can also affect the mouth. In contrast, lichen sclerosus is characterized by white, itchy spots that commonly appear on the vulva of older women.
Understanding Lichen Planus
Lichen planus is a skin condition that is believed to be caused by an immune response, although the exact cause is unknown. It is characterized by an itchy, papular rash that typically appears on the palms, soles, genitalia, and flexor surfaces of the arms. The rash often has a polygonal shape and a distinctive white-lines pattern on the surface, known as Wickham’s striae. In some cases, new skin lesions may appear at the site of trauma, a phenomenon known as the Koebner phenomenon.
Oral involvement is common in around 50% of patients, with a white-lace pattern often appearing on the buccal mucosa. Nail changes may also occur, including thinning of the nail plate and longitudinal ridging. Lichenoid drug eruptions can be caused by certain medications, such as gold, quinine, and thiazides.
The main treatment for lichen planus is potent topical steroids. For oral lichen planus, benzydamine mouthwash or spray is recommended. In more extensive cases, oral steroids or immunosuppression may be necessary.
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This question is part of the following fields:
- Dermatology
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Question 30
Incorrect
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A 25-year-old man is brought to the Emergency Department by his friends. Around 2 hours ago he was allegedly assaulted outside of a bar. He was repeatedly punched in the head and has sustained some bruising around his eyes. His friends report that he is 'concussed' and say that he is confused. On examination his GCS is 14 (M6 V4 E4) and he has trouble explaining where he is. There are no focal neurological features. There is no past medical history of note. Tonight he has drunk around four pints of lager. What is the most appropriate management with regards to a possible head injury?
Your Answer:
Correct Answer: CT head scan within 1 hour
Explanation:According to the latest NICE guidelines, a CT head scan is necessary for this patient as their GCS remains below 15 after 2 hours.
NICE Guidelines for Investigating Head Injuries in Adults
Head injuries can be serious and require prompt medical attention. The National Institute for Health and Care Excellence (NICE) has provided clear guidelines for healthcare professionals to determine which adult patients need further investigation with a CT head scan. Patients who require immediate CT head scans include those with a Glasgow Coma Scale (GCS) score of less than 13 on initial assessment, suspected open or depressed skull fractures, signs of basal skull fractures, post-traumatic seizures, focal neurological deficits, and more than one episode of vomiting.
For patients with any loss of consciousness or amnesia since the injury, a CT head scan within 8 hours is recommended for those who are 65 years or older, have a history of bleeding or clotting disorders, experienced a dangerous mechanism of injury, or have more than 30 minutes of retrograde amnesia of events immediately before the head injury. Additionally, patients on warfarin who have sustained a head injury with no other indications for a CT head scan should also receive a scan within 8 hours of the injury.
It is important for healthcare professionals to follow these guidelines to ensure that patients receive appropriate and timely care for their head injuries. By identifying those who require further investigation, healthcare professionals can provide the necessary treatment and support to prevent further complications and improve patient outcomes.
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This question is part of the following fields:
- Neurology
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